The project's objective is to develop, test and evaluate a model service delivery system, to be used to community mental health centers in responding to the multipl needs of certain high-risk elderly persons. By facilitating access to mental health and other service providers, the system serves a preventive mental health function. The system does not itself provide direct services. Rather, it links clients with individualized packages of comprehensive services (primarily in the community) and ensures continuity of services. The system's components include individualized, comprehensive assessment and screening; a goal setting and planning procedure which includes the client; referral to service providers; follow-up by a case manager; and periodic reassessment and re-referral. The mental health center maintains a client record system that integrates the system's components for individual clients. The system will be economical and relatively undemanding of professional time becaus it is designed to be operated by volunteers and para-professionals, with consultation and supervision from professions. The project will develop methods for applying the findings of a community survey in the planning of the service delivery system, particularly in identifying groups which are being served, groups which need services and gaps in the availability of services.